MODELS OF GERIATRICS PRACTICE; The Hospital Elder Life Program: A Model of Care to Prevent Cognitive and Functional Decline in Older Hospitalized Patients

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A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics.

C Viscoli, Jane Hurst, Alan R. Horwitz … (1993)

To prospectively develop and validate a predictive model for the occurrence of new delirium in hospitalized elderly medical patients based on characteristics present at admission. Two prospective cohort studies done in tandem. University teaching hospital. The development cohort included 107 hospitalized general medical patients 70 years or older who did not have dementia or delirium at admission. The validation cohort included 174 comparable patients. Patients were assessed daily for delirium using a standardized, validated instrument. The predictive model developed in the initial cohort was then validated in a separate cohort of patients. Delirium developed in 27 of 107 patients (25%) in the development cohort. Four independent baseline risk factors for delirium were identified using proportional hazards analysis: These included vision impairment (adjusted relative risk, 3.5; 95% Cl, 1.2 to 10.7); severe illness (relative risk, 3.5; Cl, 1.5 to 8.2); cognitive impairment (relative risk, 2.8; Cl, 1.2 to 6.7); and a high blood urea nitrogen/creatinine ratio (relative risk, 2.0; Cl, 0.9 to 4.6). A risk stratification system was developed by assigning 1 point for each risk factor present. Rates of delirium for low- (0 points), intermediate- (1 to 2 points), and high-risk (3 to 4 points) groups were 9%, 23%, and 83% (P < 0.0001), respectively. The corresponding rates in the validation cohort, in which 29 of 174 patients (17%) developed delirium, were 3%, 16%, and 32% (P < 0.002). The rates of death or nursing home placement, outcomes potentially related to delirium, were 9%, 16%, and 42% (P = 0.02) in the development cohort and 3%, 14%, and 26% (P = 0.007) in the validation cohort. Delirium among elderly hospitalized patients is common, and a simple predictive model based on four risk factors can be used at admission to identify elderly persons at the greatest risk.

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The natural history of functional morbidity in hospitalized older patients.

Connie L. Sommers, Jeppe A. Olsen, Etienne Hirsch … (1990)

This study provides data on changes in the functional status of older patients that are associated with acute hospitalization. Seventy-one patients over the age of 74 admitted to the medical service of Stanford University Hospital between February and May 1987 received functional assessments covering seven domains: mobility, transfer, toileting, incontinence, feeding, grooming, and mental status. Assessments were obtained by report from the patient's caregiver (or the patient when he or she lived alone) for 2 weeks before admission; from the patient's nurse on day 2 of hospitalization and on the day before discharge; and again from the caregiver (or patient) 1 week after discharge. The sample had a mean age of 84, covered 37 Diagnostic Related Groups, and had a median length of stay of 8 days. Between baseline and day 2, statistically significant deteriorations occurred for the overall functional score and for the individual scores for mobility, transfer, toileting, feeding, and grooming. None of these scores improved significantly by discharge. In the case of mobility, 65% of the patients experienced a decline in score between baseline and day 2. Between day 2 and discharge, 67% showed no improvement, and another 10% deteriorated further. These data suggest that older patients may experience a burden of new and worsened functional impairment during hospitalization that improves at a much slower rate than the acute illness. An awareness of delayed functional recovery should influence discharge planning for older patients. Greater efforts to prevent functional decline in the hospitalized older patient may be warranted.

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Screening for frailty: criteria and predictors of outcomes.

Peter W M Chung, B Gerety, F. Domínguez … (1991)

To determine the reliability of rapid screening by clinically derived geriatric criteria in predicting outcomes of elderly hospitalized patients. Prospective cohort study of 985 patients screened at the time of hospital admission and followed for 1 year with respect to the outcomes of mortality, hospital readmission, and nursing home utilization. Palo Alto Veterans Affairs Medical Center, a tertiary care teaching hospital. Male patients 65 years of age and older admitted to the Medical and Surgical services during the period from October 1, 1985 through September 30, 1986. Patients were grouped by specific screening criteria into three groups of increasing frailty: Independent, Frail, and Severely Impaired. Each criterion focused on a geriatric condition and was designed to serve as a marker for frailty. Increasing frailty was significantly correlated with increasing length of hospital stay (P less than 0.0001), nursing home utilization (P less than 0.0001), and mortality (P less than 0.0001). Multivariate analyses revealed that the clinical groups were more predictive of mortality and nursing home utilization than were age or Diagnosis-Related Groups (DRGs). Rehospitalization was unrelated to age, clinical group, or DRG, suggesting that utilization may not be driven by the clinical factors measured in this study. Rapid clinical screening using specific geriatric criteria is effective in identifying frail older subjects at risk for mortality and nursing home utilization. Our findings suggest that geriatric syndromes are more predictive of adverse outcomes than diagnosis per se. This well operationalized screening process is inexpensive as well as effective and could easily be introduced into other hospital settings.